The politics of pain
Law enforcement is clamping down on doctors who prescribe high doses of the most powerful and dangerous pain killers. Is this protecting patients - or hurting them?
UNTIL HE CLOSED his northern Virginia practice in 2002, Dr. William E. Hurwitz was a nationally known pain specialist whose willingness to treat chronic pain with high doses of powerful narcotic pain killers like Oxycontin and Dilaudid had attracted patients from around the country. Many of them saw Hurwitz as a savior offering deliverance from years of agony that other doctors had been unwilling to treat. Hurwitz's liberal prescribing got him profiled on ''60 Minutes.'' Twice, in 1991 and 1996, it also got his medical license suspended. And a week and a half ago, it got him sentenced to 25 years in a federal prison.
Hurwitz's was the most visible conviction in a three-year federal investigation of prescription drug abuse, a crackdown triggered by a widely reported rash of Oxycontin addictions in the late 1990s. According to prosecutors, Hurwitz's willful ignorance of the fact that some of his patients were using their pain killers recreationally or turning around and selling them was tantamount to running a drug ring out of his office. A few of his patients, the prosecution charged, suffered severe overdoses at his hands, one dying after Hurwitz prescribed her morphine at a dose 45 times higher than anything she had previously taken. As Drug Enforcement Administration chief Karen P. Tandy put it, ''Dr. Hurwitz was no different than a cocaine or heroin dealer peddling poison on a street corner.''
To Hurwitz's defenders, however, he was a victim of drug hysteria and of a cruel disregard for the destructive power of chronic pain. And while few pain doctors would defend all the particulars of Hurwitz's practice, many are deeply worried about the example that his conviction sets. According to Russell K. Portenoy, a neurologist and leading pain care specialist, the case is sure to scare doctors into undertreating pain. ''The chilling effect from this is profound,'' he argues, ''and the bottom line is that it's bad for the public health.''
The fierce disagreement over Hurwitz's case and others (one doctor, in Florida, is serving a 63-year sentence for manslaughter because of patient overdoses) hinges on the question of what doctors can and cannot do to treat pain. Partly, this is a medical question: Alleviating pain is medicine's oldest goal, but as a medical specialty pain management is barely 50 years old, and researchers are still working out the complexities inherent in the question of why we hurt. But cases like Hurwitz's also illuminate shifting societal attitudes about the meaning of pain - and about the risks we are willing to take to treat it.
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The founding father of pain medicine was John J. Bonica, an Italian-born American anesthesiologist whose intimacy with the topic stemmed in part from the 14 years he spent moonlighting as a professional wrestler. During World War II, Bonica was chief of anesthesia of an Army hospital filled with soldiers injured in the Pacific theater. The patients he saw there - many suffering from neurological disorders and post-amputation syndromes like phantom limb - convinced him that the medical understanding of pain was woefully inadequate.
At the time, pain was understood solely as a symptom. To treat it, doctors thought, one need only treat the underlying illness. According to Marcia Meldrum, a UCLA historian of medicine, ''Pain was something - to doctors - that could tell you where the disease was, and it was often thought of as an indication that the body was fighting disease.''
This understanding was fed by larger public attitudes about pain, says Meldrum. ''There was wide cultural support for the idea that the endurance of pain was a virtue, both in the context of childbirth and in the context of disease.''
But in not taking pain seriously, Bonica argued, doctors were consigning their patients to undue suffering. They were also drastically oversimplifying the phenomenon itself. In fact, pain can outlive its original stimulus, so that curing the underlying disease doesn't bring any relief. In other cases, like phantom limb, the neurological system will just start broadcasting false pain signals, to excruciating effect.
In the decades since the publication of Bonica's seminal 1953 textbook, ''The Management of Pain,'' pain medicine has grown in visibility and importance, led by doctors like Kathleen Foley, a neurologist at New York's Memorial Sloan-Kettering Cancer Center, and Portenoy, at New York's Beth Israel Medical Center. Today most major hospitals have pain care units, and specialized pain clinics around the country are thriving. Medical schools have started to incorporate pain management into their curricula.
Still, as recently as 2002, a National Institutes of Health study found that 26 to 41 percent of cancer patients were inadequately treated for pain. Other studies suggest that as many as half of the estimated 50 million Americans who suffer from some form of chronic pain still don't find relief. And the problem is not just a matter of discomfort. According to Michael A. Ashburn, an anesthesiologist at the pharmaceutical firm ZARS and, like Portenoy, a past president of the American Pain Society (and also the government's primary expert witness in the Hurwitz case), ''There's a clear body of evidence in the scientific literature showing that poorly controlled pain can impede the healing process in people undergoing surgery and increases the risk of harm and death.''
Medically speaking, then, pain has come to be understood not as the character-building crucible of old but as a dangerous medical problem. As a result, doctors have started to look to stronger measures to treat it - including so-called opioid analgesics like morphine and oxycodone (the active ingredient in Oxycontin). According to Portenoy, such drugs are ''by far the most reliable and the most powerful analgesics available to humankind.''
While morphine was the wonder drug of the 1800s, for most of the 20th century doctors prescribed such drugs sparingly, partly out of addiction concerns and partly from fear of prosecution. In the three decades after the 1914 passage of the Harrison Act, the nation's first drug law, 25,000 doctors were arrested for prescribing opiates.
In the 1970s, however, doctors treating terminal cancer found that their patients were much less likely than had previously been feared to develop an addiction - or even to experience the trademark opiate high. As a result, physicians began to see opioids as a possible treatment for more ordinary types of chronic pain, such as back pain or rheumatoid arthritis. In a highly influential 1986 paper, Portenoy and Foley argued that opioid therapy could be ''a safe, salutary, and more humane alternative'' to existing treatments for chronic pain. Two other pain specialists, J. David Haddox of Emory University (now an official at Purdue Pharma, maker of Oxycontin) and David E. Weissman of the University of Wisconsin, coined the term ''pseudo-addiction'' to describe how some patients who displayed what might be seen as addictive behavior were simply trying to treat their pain.
Other pain doctors, however, remain unconvinced. None dispute the efficacy of such compounds in treating certain sorts of pain. Some, however, do calculate the risks differently. A few studies, for example, have suggested that Portenoy and Foley's addiction numbers are too low, and such concerns have only grown louder in the wake of the Oxycontin scare.
Other doctors have suggested that opioids are not always as effective as claimed, and may in fact exacerbate some kinds of pain. Joel R. Saper, a neurologist who heads the Michigan Head Pain and Neurological Institute, was the lead author of a paper published last June in the journal Neurology that reported the results of a study following 160 of his patients taking opioids daily for severe headaches. Saper describes the results as ''abysmal.''
''Only 26 percent of the people reported feeling any better,'' and much of that was ''questionable improvement,'' he says. ''A lot of people did poorly, and there was a lot of mischief. People were diverting drugs, abusing them, all of that.'' In addition, Saper goes on, opioids can make some chronic headaches worse, a phenomenon known as ''rebound headache.''
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All of this, however, seems rather academic to activists like Siobhan Reynolds, president of the patient advocacy group the Pain Relief Network. As she sees it, chronic pain sufferers know what has worked for them in the past and they should be allowed to risk addiction if they so choose. ''Pain,'' says Reynolds, ''is an opioid deficiency syndrome.'' The idea of doctors debating whether to prescribe opioids is as absurd to her as ''diabetes specialists arguing about whether or not to use insulin.''
''We've been there, we've seen the promised land,'' says Reynolds, whose husband suffers from chronic pain. ''We know that if you have enough opioids, you can get up, go to work, and take care of your family. But sometimes it takes quite a lot, way more than law enforcement wants doctors to prescribe.''
The sort of opioids-as-deliverance rhetoric favored by some patient advocates - and by the pharmaceutical companies that develop and market such drugs - worries even Portenoy, who remains an advocate of aggressive, monitored opioid treatment for chronic pain.
''We have to be careful about not over-promising,'' he says. ''Patients have to have reasonable expectations about what can be done. Perhaps we have oversold what pain management can do, perhaps some people have oversold what opioids can do.''
But, he goes on, that's not to say pain is just something we have to live with: ''No pain specialist should be saying that it's OK for the body to feel pain. That's just wrong.''
Drake Bennett is the staff writer for Ideas. Email firstname.lastname@example.org.